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2 1, �� APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES oA,)"VDvl�y ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468—a44-73q--'" PEMIT UPIRBU I YEAR PM PATE ISSUED (Complete in Triplicate) Application Is hereby made°to San Joaquin County for a permii'to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address -. F.� d CW B-J`s City _OSL!b_`*amu Lot Size/Acreage s Owner's Name _ ��tr1 l�lJ!r; GA,h&Address �•�']• ��InL�5I LNf., d�nxphone � � 1 Contractor � �Address I License No.ygZ Phone : _TYPE AF-WELL/P.UM :.,.�,s a,,,r s.,,,,NEW WELL ❑- _ - -,--WELL REPLACEMENT-n , DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR I-7 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f7I Industrial ❑ Open Bottom w ❑ Manteca, Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack CT3_6cyr r Type of Casing Specifications M Public C] Other 0 DeltaTM Depth of Grout Seal Type of Grout I M Irrrpaaon _.Approx. Depth ",Z Eastsrnr` Surface Sedl Installed by Repair Work Done U Type of Pump H,P. State Work Done Weft Destruction O Weil Diameter sealing Material i Depth -+ Depth r:s _.Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION gL REPAIR/ADDITION Ll DESTRUCTION G INo septic system permitted if public sewer is d k available within 200 feet,! Installation will serve: Residence %/ Commercial—•Other--^'^� ^�-- Number of living units: Number of bedrooms 3 ) Charactef of soil to a depth of 3 feet: `.; SEPTIC TANK 9 Type/Mfg Capacity. _� Water tallo. Compartments ments 2 _ ' PKG. TREATMENT PLT, Cl 1"nr-�"� Method o1 Ois�sal k Distance to nearest: WeN � � Foundation �_ Property Line475 _ _ S LEACHING LINE ; &_Length of lines _— '`z ' ,= Tot?[ length/size FILTER BED n Distance to nearest: Well JCA Foundation Property Line SEEPAGE PITS I I Depth Cf Sire .. all �Z _ Number SUMPS K Distance to nearest: Well- 15b _ Foundation_ -La Property Line 11 DISPOSAL PONDS C7 I hereby certify that I have prepared this application and that-the work will be done in accordance with San Joaquin county ordinances, state laws, and ; rules and regulations of the Sen Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employanyperson in such manner as to become subject to workman's compensation laws of California.•' Contractor's hiring or sub-contracting signature e certifies the following: "I certify that in the perforManci.of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." " ' 1 The applicant must call for all required inspections. Complete drawing on reverse side. Signed I. Title: _. G•-r�e� 2Z � — Data: ��-- 9.�. R DEPARTMENT USE ONLY k Application Accepted by Date �a res Pit or Gout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PER[dIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REWrTEO CK CASH RECEIVED BY DATE PERMIT'NO. r EN 19.211RtV.1/NSl �`t 51� �� EH 91•Zs t